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Outer Retinal Morphology and Visual Function in Patients with Idiopathic Epiretinal Membrane

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Outer Retinal Morphology and Visual Function in Patients with Idiopathic Epiretinal Membrane CLINICAL SCIENCES Outer Retinal Morphology and Visual Function in Patients With Idiopathic Epiretinal Membrane Ken Watanabe, MD; Kazushige Tsunoda, MD, PhD; Yoshinobu Mizuno, MD; Kunihiko Akiyama, MD; Toru Noda, MD Objective: To determine the relationship between the uted to the BCVA. The standardized partial regression morphology of the fovea and visual acuity in patients with coefficient ␤ was 0.415 for the COST line, 0.287 for the an untreated idiopathic epiretinal membrane (ERM). IS/OS junction line, and 0.247 for the external limiting membrane. However, the other features, eg, foveal bulge, Methods: We examined 52 eyes of 45 patients diag- inner limiting membrane, foveal pit, and ERM, were not nosed with an ERM. The morphology of the foveal area was significantly associated with the BCVA. The central reti- determined by spectral-domain optical coherence tomog- nal thickness was significantly correlated with the BCVA raphy. The relationships between the best-corrected vi- (r2=0.274; PϽ.01). sual acuity (BCVA) and 8 optical coherence tomography features, central retinal thickness, cone outer segment tip Conclusions: At an early stage of an ERM, only the pho- (COST) line, photoreceptor inner/outer segment (IS/OS) toreceptor structures are significantly associated with the junction line, foveal bulge of the IS/OS line, external lim- BCVA, and the appearance of the COST line was most iting membrane, inner limiting membrane, foveal pit, and highly associated. Detailed examinations of the photo- ERM over the foveal center, were evaluated. receptor structures using optical coherence tomogra- phy may help find photoreceptor dysfunction in cases Results: Multiple regression analysis showed that in- of idiopathic ERM. tact COST line, IS/OS junction line, and external limit- ing membrane independently and significantly contrib- JAMA Ophthalmol. 2013;131(2):172-177 PTICAL COHERENCE TO- segment/outer segment (IS/OS) junction mography (OCT) is a line, detected by SD-OCT in patients with useful method of detect- an ERM.7-10 ing early morphological The diagnostic value of determining the changes in retinas af- integrity of the IS/OS junction line and the Ofected by various pathological condi- cone outer segment tip (COST) line by SD- tions. The correlations between the vi- OCT has been done primarily on dis- sual acuity and the morphological changes eases of the outer retina, eg, acute zonal in the retina have been reported for vari- occult outer retinopathy11 and hereditary ous retinal diseases, such as age-related macular dystrophies.12-14 However, in eyes macular degeneration,1 central serous cho- with an ERM, the appearance of the pho- rioretinopathy,2 macular edema,3,4 idio- toreceptor microstructures in the SD- pathic macular hole,5,6 and epiretinal mem- OCT image can be affected by retinal thick- brane (ERM).7-9 ening, subretinal cysts, and the ERM itself. Retinal traction caused by an ERM leads These alterations lead to a reduction in the to morphological changes of not only the intensity of the laser light reaching the pho- superficial layers of the retina but also the toreceptor layer. In addition, the clarity of entire retina including the photoreceptor the SD-OCT images of the outer retina, eg, layer. This is important because long- the Henle layer, IS/OS junction line, and standing morphological changes can lead COST line, is dependent on the inci- to functional damages and cause meta- dence angle of the laser beam on the retina, morphopsia and decreased visual acuity. which would be altered by an ERM.15,16 Spectral-domain OCT (SD-OCT) has Thus, the diagnostic value of examining enabled clinicians and investigators to ob- the photoreceptor microstructures by SD- Author Affiliations: tain clearer images of the microstructure OCT in eyes with an ERM may not be as Author Aff Department of Ophthalmology, of the photoreceptor layer than time- reliable as in cases of acute zonal occult Departmen National Tokyo Medical Center domain OCT. Several studies have exam- outer retinopathy and other outer retinal National To (Drs Watanabe, Akiyama, and (Drs Watan Noda), and Laboratory of Visual ined whether significant correlations ex- diseases where the inner retinal altera- Noda), and Physiology, National Institute of ist between macular dysfunction and the tions do not attenuate the laser energy. Physiology, Sensory Organs (Drs Tsunoda integrity of photoreceptor microstruc- The purpose of this study was to evalu- Sensory Or and Mizuno), Tokyo, Japan. tures, especially the photoreceptor inner ate the relationship between deteriora- and Mizuno JAMA OPHTHALMOL/ VOL 131 (NO. 2), FEB 2013 WWW.JAMAOPHTH.COM 172 ©2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 tion of the best-corrected visual acuity (BCVA) and ab- the foveola. We graded it normal when the bulgelike appear- normalities of the photoreceptor microstructures in ance was clearly observed and graded it abnormal when the patients with untreated idiopathic ERM. To accomplish bulgelike appearance was not observed and the IS/OS junc- this, we examined cases with ERM without severely de- tion line appeared flat. formed inner structures, such as a lamellar hole and large The ILM was graded normal when it looked smooth and flat at the fovea and was graded abnormal when it looked wrinkled cystic formations. We classified the abnormalities of the or distorted. The foveal pit was graded normal when the con- retina in the SD-OCT images and performed multiple re- cave retinal surface was clearly observed at the foveola and graded gression analyses to determine which parameter was in- abnormal when the foveal surface appeared flat. The ERM was dependently and significantly associated with the BCVA graded normal when the ERM did not overlap the foveola and in cases of ERM. graded abnormal when the ERM was attached over the foveola. The relationship between these 8 OCT features and the vi- sual acuity was statistically examined. Statistical analysis was per- METHODS formed using SPSS version 19.0 (SPSS Japan). The visual acuity was converted to logMAR units for the statistical analyses. Pear- This was a retrospective case series performed in the Department son correlations were performed to determine the association be- of Ophthalmology, National Tokyo Medical Center, Tokyo, Japan. tween CRT and visual acuity. The Mann-Whitney test was used After an explanation of the procedures to be used, an informed con- to compare the BCVA and CRT between the normal and abnor- sent was received from all of the subjects for the tests. The proce- mal groups for each OCT feature. Multiple regression analysis was dures used adhered to the tenets of the Declaration of Helsinki, and performed with BCVA and CRT as the dependent variables and approval to perform this study was obtained from the review board/ with the integrities of 7 OCT features as independent variables. ethics committee of the Tokyo Medical Center. A P value Ͻ.05 was considered significant. We examined 52 eyes of 45 patients (20 eyes of 18 men and 32 eyes of 27 women, mean [SD] age, 67.0 [10.0] years) diag- RESULTS nosed with an ERM without lamellar holes or apparent cystic changes in the fovea. The patients were examined between Oc- tober 2009 and September 2010. The exclusion criteria were We first evaluated the normal fellow eyes of 29 of the 45 myopia more than 6 diopters, advanced lens opacification, other patients studied (13 eyes of 13 men and 16 eyes of 16 ocular disease that could cause visual disturbances, secondary women; mean [SD] age, 66.0 [8.1] years). For these, all ERM caused by vascular diseases, uveitis, and retinal detach- 18 ment. Cases whose OCT images did not have enough signal of the 7 OCT features were judged normal. intensity for evaluation, ie, average intensity of the SD-OCT sig- Two representative cases demonstrating how the OCT nal was less than 8 of 10, were also excluded. features were judged to be either normal or abnormal are Spectral-domain OCT (Cirrus HD-OCT, versions 4.5 and shown in Figure 1B and C. A horizontal SD-OCT scan 5.1; Carl Zeiss Meditec) was used to obtain tomographic im- image of the left retina of a 74-year-old man is shown in ages of the retina. Following dilation of the pupil, 5 line-scan Figure 1B. The ELM, foveal bulge, IS/OS junction line, images were obtained both horizontally (length, 9.0 mm) and and COST line were clearly observed and judged to be vertically (length, 6.0 mm) across the foveola, with the dis- normal. An ERM was present over the foveola, and this tance between each scan line of 0.075 mm. Cases where any of was judged to be abnormal. The foveal pit was concave the scan lines did not pass through the foveola were excluded. and judged to be normal. The ILM was partially wrinkled Eight SD-OCT features were evaluated: (1) central retinal thickness (CRT), (2) COST line, (3) IS/OS junction line, (4) at the foveola and judged abnormal. bulgelike appearance of the IS/OS junction line at the foveola A vertical SD-OCT scan image of the right retina of a (foveal bulge), (5) external limiting membrane (ELM), (6) in- 65-year-old woman is shown in Figure 1C. The IS/OS ternal limiting membrane (ILM), (7) foveal pit, and (8) ERM junction line and ELM were clearly observed and judged formation over the foveal center. to be normal. The foveal bulge and COST line could not The CRT was defined as the distance between the inner reti- be seen at the fovea and were judged abnormal. The ILM nal surface and inner surface of the retinal pigment epithe- was wrinkled in the parafoveal region; however, the fo- lium at the foveola (Figure 1A).
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